For aspiring coders, is there a knowledge gap between the classroom and the workplace?

There’s little doubt that on-the-job training provides the kind of hands-on experience that no classroom setting can truly replicate. It easily could be said of most industries that there is a divide between book knowledge and the real world, but in the case of the coding profession, a growing number of industry experts believe that the current gap is too wide.

“We’re not addressing the big issues … and one of the reasons that we have a shortage is that there is a disconnect between what is learned and what happens on the job,” says Angela Carmichael, RHIA, CDIP, CCS, assistant vice president of coding and auditing for Pyramid Healthcare Solutions. “There are a lot of people who study coding but can’t code at 95% accuracy after their training.”

Since most hospitals expect the kind of quality output that equates to 95% coding accuracy from their coding departments, many are reluctant to give new graduates a chance. It’s a frustration across the industry that some believe is unfair and unrealistic.

“With any classroom setting that is preparing someone for a professional job, there is always going to be a different experience,” says Claudia Tessier, RHIA, MEd, principle with Coding for Healthcare Professionals, adding that with coding education, students don’t have access to a complete record or the workflows inherent to a hospital environment. “There is only a certain degree to which any classroom will duplicate a real work environment.”

According to Linda Donahue, RHIT, CCS, CCS-P, CPC, an associate professor of HIT at Delgado Community College in Louisiana, today’s hospitals expect students to automatically know everything about coding and billing, but a two-year program can cover only so much material. “It would take years to train students to work in all work settings,” she notes. “We primarily focus on inpatient vs. outpatient settings and teach them how to research and network in order to find more guidelines and processes specific to their work setting.”

When Carmichael entered the workforce in the 1980s, HIM managers had the time to mentor and train new employees. That’s not the case anymore. “Coding managers today have so much more responsibility. Some don’t have time to invest in their own skills,” she explains.

Coding professionals point out that a conundrum exists in the industry: Colleges are limited by tight two-year curriculums requiring that many facets of HIM and coding be covered, while hospitals are limited in the resources they can devote to mentoring and training new employees.

If avenues were available to provide more intern or mentoring programs, many believe it would be a win-win both ways. “Employers want to hire coders with experience, but a new coder has no bad habits … and it is easier to teach new habits than to correct old ones,” Donahue says.

New Grads Need Not Apply
Kathryn DeVault, RHIA, CCS, CCS-P, director of HIM solutions at AHIMA and an instructor at Arapahoe Community College in Colorado, suggests that while more on-the-job training would be helpful, hospitals currently face a huge risk in expending limited resources on training new coders. “It takes six months to get someone up to coding at a level needed in a hospital setting,” she says. “What if they invest the resources and the coder leaves?”

Sylvia Alcala, MA, RHIA, CDIP, CCS, CPC, an AHIMA-approved ICD-10-CM/PCS trainer and a coding instructor at Texas State University, agrees, pointing out that in today’s lean staffing situation, hospital HIM departments can’t risk losing productivity to get a new graduate up to speed. “Most coding departments want hires to hit the ground running,” she explains. “That is, they would rather spend as little time as possible training and hire a coder with experience so there is minimal disruption to the department as far as resource requirements.”

Because coding is such a complicated function in hospitals, DeVault says educational programs could devote the entire two years to coding education and gaps in knowledge would still likely exist. Currently, coding is just one piece of a two-year program to reach RHIT certification.

DeVault says that while educational programs “should be giving [students] a good enough education to pass a hospital coding test,” there is still the issue of understanding how it all comes together from a hospital workflow perspective. Exacerbating the problem is the fact that every healthcare organization does things just a little differently. “You can’t expect graduates to understand the nuances inherent in the individual workflows of an organization,” she says.

Another major concern, according to Alcala, is the lack of technology in a classroom setting, noting that students typically use the ICD and CPT manuals as their primary learning tools, but 95% of workplaces employ sophisticated computer programs. “If you want to test for a coding certification, you are tested using the books,” she says.

With more organizations training existing employees to fill future coding gaps, the odds of new graduates gaining a foothold are becoming even more stacked. Transcription professionals in particular are attractive candidates to make this sort of transition because their skill set is closely aligned with coding, and many are staring at an uncertain employment future. “The pool of resources from within an organization for coders is far larger than in the past,” Tessier notes, adding that hospitals are prioritizing individuals with some kind of clinical background.

A high level of clinical knowledge will be an important attribute for future employment, according to Carmichael, pointing to the intricacies associated with the coming ICD-10 transformation. “We need to reengineer the classroom and specifically expand to a more biomedical focus,” she says.

Challenges to Improving Education
Professionals agree that the answer to the current disconnect is better collaboration between hospitals and schools. One primary need from a hospital perspective is that new coders need to understand how to code from a full record. “That is a very high-level skill set,” Donahue says.

However, because most healthcare organizations will not allow students to use facility computers due to concerns over potential HIPAA violations, Donahue says educators have difficulty schooling students on the art of coding from a full record. “We contract with these facilities,” she says, adding that students provide background checks, drug screenings, and signed confidentiality agreements. “If there are old, previously coded paper records available, the students may get to code them and possibly ask questions. They are trained to work on encoders in the AHIMA virtual lab but don’t get a chance to utilize these skills.”

Because students can’t practice their skill sets in a manner that adds value to their knowledge base, Donahue’s program has stopped sending students to healthcare facilities. “They spend two days per week in our lab or working from home completing projects. We are trying to prepare them to work in a variety of settings by requiring project-oriented assignments on legal and regulatory issues, coding, and reimbursement-related topics,” she says.

While challenges exist to getting students real-world experience, some healthcare organizations are developing apprentice programs for new graduates with the hopes of addressing future coding shortages. Although these are few and far between, according to DeVault, there is hope. “In Colorado, we have some hospitals offering apprentice programs, and they are more open to taking new graduates,” she says. “[However], it’s a struggle” to get more hospitals onboard.

DeVault credits a large nearby facility for implementing a coding school for new graduates but wishes it could affect more careers. “This is wonderful, but it only accommodates a few of our graduates,” she says. “We need to have our students do externships at facilities where they can be identified as potential employees and get real-world experience in a variety of settings.”

ICD-10’s Impact
As ICD-10 nears, some industry professionals believe a couple factors will level the playing field somewhat for new graduates. First, ICD-10 will produce greater demand for coders, forcing hospitals to consider a larger pool of candidates.

“If there is restricted access to incoming coders by employers, sooner or later you see the demand for coders increase to the point where I believe employers will be forced to offer training programs on the job or a combination of classroom curriculum and on-the-job training,” Alcala says.

When ICD-10 comes online in 2014, new graduates could have an advantage in that their education will have centered on the new system. “I think [employment prospects] will improve greatly,” Donahue says. “Students coming out of college will be fully educated in the new coding system.”

One of the greatest challenges to education curriculums is determining where the overlap between ICD-9 and ICD-10 begins and ends. “When do we stop 9 and start teaching 10?” Tessier asks. “I see some great value in still learning 9 and then going into 10.”

Donahue says new coding students will not need to be trained in ICD-9 if they are graduating in the spring of 2014 or later because the coding certification exams will be changed to ICD-10 by that time.

“There are plenty of coders trained in ICD-9 to assist with the transition and work those old claims,” she says. “The new graduates will be fully trained in ICD-10. Some older coders may choose to retire rather than learn this new coding system, providing more opportunities for new coders to work in inpatient facilities with a limited amount of training.”

The overlap between ICD-9 and ICD-10 will compound the problems of an already tight curriculum schedule when it comes to coding, DeVault says. In fact, she believes that integrating ICD-10 into the current course load is educators’ greatest challenge. “We had a conversation last week about needing another class for ICD-10,” she notes. “We couldn’t do it.”

While many experts believe ICD-10’s arrival will create opportunities for new graduates, Carmichael is skeptical. A background in ICD-9 will go a long way toward helping established coders navigate the new system, she points out, plus ICD-10 will require more experience with and understanding of clinical concepts.

“You have to have better biomedical skills,” Carmichael says. “We’re starting to get the message out there, but I’m not sure schools are making changes appropriately.”

Possible Solutions
Understanding the need to leverage new graduates in light of coming coder shortages, AHIMA is looking to put together programs that will help bridge the gap. DeVault says the best partnerships will need to occur on the state level, adding that educational institutions need to be proactive in seeking out those types of relationships. “In Colorado, we are working closely with our state AHIMA organization to build programs between hospitals and the school itself,” she explains. “I would suspect in most states the educators know the HIM directors. They need to try to put students in internships.”

Both Donahue and Carmichael believe that changes to the credentialing system also would help. Specifically, more specialized tracks that go deeper than just differentiating between inpatient and outpatient likely would give hospitals more confidence in the abilities of new graduates, Carmichael says. “You can’t really distinguish coders with the current credentials,” she notes, adding that the credentialing tests aren’t particularly challenging. “We need credentials specific to the account type.”

Tessier believes something will have to change to prepare the industry for the future and adequately fill the staffing needs of healthcare organizations.
“I can see where those coming right out of school would not be high priority, but they can’t be ignored,” she says, “and their potential will be increasingly recognized.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.